Connor, who had a learning disability and epilepsy, died in 2013 while receiving care at an Oxfordshire treatment centre run by Southern Health NHS Trust.

Initially the trust classified Connor’s death as a result of natural causes after he drowned in a bath.

Following campaigns by his family, an independent investigation found his death was entirely preventable, there had been failures in his care and neglect had contributed to it.

Richard Handley died shortly after undergoing surgery

Richard Handley had lifelong problems with constipation, exacerbated by his Down’s syndrome and medication.

He died in 2012, days after being admitted to Ipswich Hospital from a supported living unit run by the United Response charity. A review found Richard’s health needs were overlooked, confirming his family’s fears.

Not all deaths would represent a medical failing or problem with the way the person had been supported during their life, said the report.

Key findings

The level of acceptance and sense of inevitability when people with a learning disability or mental illness die early is too common

There is no consistent national framework in place to support the NHS to investigate deaths

A failure to prioritise learning from deaths so that action can be taken to improve care for future patients and their families

Many carers and families do not find the NHS to be open or transparent

Families and carers are not routinely told what their rights are when a relative dies, what will happen or how they can access support or advocacy

Speaking to the BBC’s Radio 5 Live, Connor Sparrowhawk’s step-father Richard Huggins said: “(For the NHS) to be consistently surprised by the data, irrespective of the type of report – whether it’s a specific one on learning disabilities or mental health, or more generally – strikes me as disappointing.

“No action” had been taken since his step-son’s death, he said, and he could not see how people would not still be dying.

‘It beggars belief’

He told the programme: “Everyone’s unexpected death is as important as anyone else’s, they should all be seen as unacceptable.

“People with mental ill-health and learning disabilities have additional issues that need to be looked at differently and specifically, otherwise they will continue to die.

“We need to stop these things happening. It beggars belief to me that it is still so endemic.”

The report said the NHS was fallible and must acknowledge and learn from mistakes.

“When a loved one dies in care, knowing how and why they died is the very least a family should be able to expect,” it said.

The CQC’s review looked at NHS trusts in England providing acute, community and mental health services, placing a particular focus on people with mental health conditions and learning disabilities.

It considered evidence from interviews with more than 100 families, visits to a sample of 12 NHS trusts and a national survey of all eligible NHS providers.

Baby Kate died when she was six hours old. It took seven years for her parents to find out why.

The CQC’s Dr George Julian said: “We must learn from these families. Their trust, honesty and candour are an example to us all.

“We owe it to them, their loved ones and to ourselves to stop talking about learning lessons, to move beyond writing action plans and to actually make change happen.”

The Health Secretary is expected to respond to the report in the Commons later on Tuesday, when he is likely to announce a requirement for trusts to collect and record information on unexpected deaths so lessons can be learned.

Mr Hunt is expected to say trusts should regularly publish this information so the public can see if progress is being made.

He is also expected to ask trusts to make a particular priority of data on outcomes for patients with learning disabilities.

‘Consistently failed’

In addition, Health Education England is expected to have to review its training of medical staff on dealing with patients and families after a tragedy.

Prof Dame Sue Bailey, chair of the Academy of Medical Royal Colleges, said: “This landmark review reveals in stark detail what many in healthcare have suspected for a long time.

“Put simply, we have consistently failed and continue to fail too many of the families of those who die whilst in our care.

“This is not about blaming individuals, but about the health service learning the lessons from this report.”

Julie Mellor, of the Parliamentary and Health Service Ombudsman, which investigates complaints about poor care, said the report provided “a golden opportunity” for NHS leaders to learn from mistakes and encourage an open, honest working environment where NHS staff do not fear reprisals.

The PHSO upheld 338 complaints into avoidable deaths in 2016, up from 2015 ‘s figure of 306.

Our Aims: About Us

To support users and ex-users of psychiatric services in the Manchester area. The organisation provides a forum for services users to have a bona fide say in planning and provision of mental health services.

Protesters in King’s Lynn fight against mental health service cuts

Protesters took to the streets of King’s Lynn to voice their anger at what they described as “continuous” cutbacks to mental health services in west Norfolk.

Mental health cuts protest

A protest march against cuts to mental health services and the Fermoy Unit at the QEH took place in King's Lynn town centre. Picture: Matthew Usher.

More than 100 campaigners marched from The Walks through the town centre before finishing outside the Majestic Cinema.

Peter Smith, former parliamentary candidate for south-west Norfolk said: “We are in the fight of our lives here.”

The protest was triggered by the Fermoy Unit, an in-patient NHS facility in Lynn for mental health, which campaigners say faces an uncertain future. The unit was briefly closed to new admissions earlier this month, but reopened last week, albeit with fewer beds.

Mr Smith said: “In my lifetime we have never had to fight like this, but what is the alternative?”

But Debbie White, director of operations for Norfolk at the Norfolk and Suffolk NHS Foundation Trust, said there were now no plans to axe the Fermoy Unit.

She added: “It is right that mental health services should be valued and funded on the same level as acute health services, and it is understandable people feel passionate about the Fermoy Unit remaining open.”

Labour party activist Jo Rust insisted the issue would not disappear. She said: “They have been talking about closing it for a long time. We will fight and we will not let them do that.”

Beth Anthony, 18 of Dersingham, said: “We are here to protest against the continuous cuts to the mental health service, we think it’s unacceptable. My younger brother suffers from poor mental health and has to travel to London... That is to the detriment of my family because we have to pay for him to go down by train every single month.”